Case 28-2010: A 32-Year-Old Woman, 3 Weeks Post Partum ......CASE STUDY PRESENTED BY: LAUREN...
Transcript of Case 28-2010: A 32-Year-Old Woman, 3 Weeks Post Partum ......CASE STUDY PRESENTED BY: LAUREN...
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C A S E S T U D Y P R E S E N T E D B Y : L A U R E N S H I R L E Y , A L L I S O N O ’ C O N N O R
A N D C A L R O B B I N S
Case 28-2010: A 32-Year-Old Woman, 3 Weeks Post Partum,
with Substernal Chest Pain
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Medical History
� 3 weeks postpartum
� First pregnancy: hypertension and preeclampsia � Normal blood pressure between pregnancies
� Second pregnancy:
¡ 1st trimester BP: 120-140/60-80
¡ 2nd trimester BP: 118-120/60-82
¡ 3rd trimester BP: 104-130/60-78 ¡ Postpartum BP: 120/80
¡ Undersized placenta (340 grams) with increased perivillous fibrin
� No medications or allergies
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Family and Social History
� Family History ¡ Parents: hypertension, hyperlipidemia ¡ Distant Cousin: stroke
� Social History ¡ Profession: physician ¡ Lives with husband, toddler, and newborn ¡ No use of alcohol, illicit drugs, or tobacco
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Onset
� 7:25 PM ¡ Patient developed left jaw and substernal chest pain ¡ Pain resolved spontaneously
� 8:00 PM ¡ Chest pain returned ¡ EMS called, pain resolved after 20 min O2 therapy
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Onset (Continued)
� 8:26 PM ¡ Pain returned (7/10) with shortness of breath
¡ EMS returned ÷ BP: 148/74 mm Hg
÷ Pulse: 90-100 bpm
÷ Interventions: Oxygen, 325mg Aspirin, Nitroglycerin (x3), Morphine 4mg
¡ Pain resolved en route, arrived at ED 8:50P
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Physical Exam
� Vital Signs ¡ Blood Pressure: 143/92 mm Hg on left, 137/81 mm Hg on
right
¡ Heart Rate: 83-92 bpm
¡ Neck: jugular vein distension (JVP 6-7 cm H2O)
¡ Cardiovascular: no murmurs, rubs, or gallops
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Labs
� ECG: ¡ Normal sinus rhythm
¡ Incomplete right Bundle Branch Block ¡ ST elevation in V2, V3
� CK MB and Troponin I were negative � Electrolytes were normal
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Diagnostic Process
� Chief Complaint: Substernal Chest Pain, Radiating to Jaw
� Possible Causes of Chest Pain: ¡ Cardiovascular ¡ Pulmonary ¡ Gastrointestinal ¡ Musculoskeletal
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Shows coronary artery dissection in the mid-to-distal left anterior descending artery (35mm long segment of narrowing, 90%
stenosis)
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Coronary Angiography-LAD
Day 0
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What is a coronary artery dissection?
� Tear in the coronary artery ¡ Inner and outer layer of the artery separate ¡ Blood pools in the area between the layers
� Tear can slow and/or block blood flow to the heart causing a heart attack, abnormalities in heart rhythm or sudden death
� Symptoms ¡ Chest Pain ¡ Rapid HR; fluttery feeling in chest ¡ Pain in arms, shoulder or jaw ¡ Shortness of breath ¡ Sweating ¡ Unusual tiredness ¡ Nausea ¡ Dizziness
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Postpartum Coronary Artery Dissections
� 75% of postpartum SCAD occur 1 day to 3 months postpartum (most occur within first 2 weeks)
� Mean age 33 y/o � 87% occur in left coronary tree
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Idiopathic Spontaneous Coronary Artery Dissection
� 75% pt’s female, premenopausal with no traditional
cardiac risk factors � 80% occur in left coronary tree � Precipitated by activities that cause coronary shear stress
¡ severe systolic hypertension ¡ cocaine use, snow shoveling ¡ weight lifting, etc. ¡ As well as seemingly benign stresses such as running, aerobics,
sneezing, etc.
� Pt.’s chest pain began right after picking up toddler
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Treatment
� There is no consensus on appropriate treatment � Case dependent � Usually a conservative approach is taken
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Conservative Treatments
� Patients who are stable and pain free � Cardiac Support
¡ Blood Thinners and Nitrates ¡ Intra-aortic Balloon Pump
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Interventional Treatments
� Patients with major or continued ischemia ¡ Percutaneous Coronary Intervention (PCI) ¡ Coronary Artery Bypass Grafting (CABG)
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Case Treatment Decisions
� Patient Information ¡ Left Anterior Descending Artery Dissection ¡ No Pain ¡ Slight Cardiac Ischemia
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Case Treatment Decisions
� Conservative Medical Treatment ¡ Intra-aortic Balloon Pump ¡ β- blockers ¡ Antiplatelet Agents (Aspirin) ¡ Anticoagulation Agent (Heparin)
� Glycoprotein IIb/IIIa was not immediately administered
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Resolution
� After 48hours ¡ Improved blood flow ¡ Dissection resolved ¡ Intra-aortic Pump Removed
2 Days
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Resolution
� Discharged after 8 days with the following regimens: ¡ Warfarin, Atenolol, Simvastatin, Clopidogrel (discontinue
after one year) ¡ Aspirin (indefinitely)
90 Days
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Pathology
� 42-85% of cases involve Adventitial Inflammation due to Eosinophils
� Eosinophils release histolytic agents which cause dissections in coronary arteries
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Cross Section of Ischemic Heart
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Questions?
Sabatine, Marc S., Farouc A. Jaffer, Paul N. Statts, and James R. Stone. "Case 28-2010: A 32-Year-Old Woman, 3 Weeks Post Partum, with Substernal Chest Pain."The New England Journal of Medicine (2010): n. pag. Web.
Case Study Citation: